HOSPITAL INFECTION CONTROL POLICY

Guideline no: ICU_03Guide2010v01.0

Guidelines for the proper use of

antimicrobials for surgical prophylaxis

TITLE Guidelines for antimicrobial surgical

prophylaxis
SUMMARY This document provides instruction and
guidance to hospital personnel on how to
manage Infection Control in their ward or
section.
All Clinical Directors, Departmental
Managers, Heads of Sections and Nursing
Officers in charge of wards are required to
instigate action to ensure the successful
implementation of the guidelines within their
area(s) of control.

DATE OF REVIEW June 2013

APPROVED and ISSUED BY:
DISTRIBUTION
RELATED DOCUMENTS
AUTHOR(S) /
FURTHER INFORMATION
Hospital Infection Control Committee
Operating theatres
MDH Guidelines for Antibiotic Treatment of
Infectious Diseases
MDH Antibiotic Team
Ext: 4540

THIS DOCUMENT REPLACES Antibiotic prophylaxis guidelines 2004

ISSUE DATE: April 2010
In conjunction with surgical specialists, the MDH Antibiotic Team has undertaken an evaluation
of local surgical prophylaxis practice and subsequent formulation of a uniform set of guidelines
for the hospital. These guidelines have been compiled following an extensive review of evidence-
based literature (particularly Scottish SIGN guideline 104), consultation with experts and – most
importantly - evaluation of local antimicrobial epidemiology. They relate only to prevention;
patients with surgical infection should be managed according to available treatment guidelines.
They do not represent the only medically or legally acceptable approach towards antimicrobial
prophylaxis in surgery and should not be considered as inclusive of all proper methods of care
nor exclusive of other methods of care reasonably directed to obtaining the same results. New
knowledge, new technologies, clinical or research data, and clinical experiences may provide
sound reasons for alternative approaches, even though they are not described in this document.
Therefore deviations under appropriate circumstances do not represent a breach of a medical
standard of care, as long as the clinical decision is based on scientifically sound principles and
the reasons for such deviations are documented in the patient’s records.

Surgical prophylaxis aims to prevent surgical site and healthcare-associated infections, thereby
reducing surgical morbidity (and mortality). Growing evidence indicates that aspects of
prescribing practice are also associated with health care associated infections, notably Extended
Spectrum B-lactamase (ESBL) and C. difficile infection with cephalosporin use. It is therefore
crucial that antibiotic prophylaxis is given judiciously and where indicated. Antimicrobial surgical
prophylaxis should:
• be undertaken only in operations where there is evidence that prophylaxis has a beneficial
effect on the incidence of post operative infection;
• target only the few major pathogens which are most relevant in terms of prevention of
infection and takes into account local antimicrobial susceptibility patterns;
• use a narrow spectrum agent that targets these pathogens and is not an important
therapeutic agent;
• be used only short term for the period of time in which (normally sterile) body tissues are
exposed to contamination during the operation.

All surgical prophylaxis should be fully documented in the patient’s records, preferably within the
“once-only medication” section of the treatment chart. All relevant details should be written,
including:
• Antibiotic name, dose and mode of administration
• Exact time of administration
• Clear statement of once-only dosage (or clear indication of no longer than 24 hour
duration, where indicated in the guidelines)

1
Summary of guideline implementation:

1. Antibiotic prophylaxis should be administered where medical evidence suggests that they
either recommended in all instances or should be considered in specific high risk
circumstances.
2. Timing of antibiotic(s):
a. Optimum timing is ≤30 minutes prior to skin incision (usually in anaesthetic room at
induction of anaesthesia),
b. Sub-optimal administration occurs if given to >1 hour prior to skin incision or post-skin
incision.
3. Recording of antibiotic: In the “once only” section of drug prescription on form. This is
preferred to recording in the anaesthetic record.
4. Choice of agent:
a. Appropriate narrow spectrum agent(s) that target the likely most important pathogens
should be adopted whenever possible. Agents used for treatment of life threatening
infections such as carbapenems, ceftazidime, tigecycline and piperacillin-tazobactam
should not be used for prophylaxis.
b. If documented beta-lactam allergy is present, alternatives should be utilised
c. Prophylactic gentamicin dosing is based on patient height (see gentamicin tables in
guidelines) and approximates to 3mg/kg/ideal body weight, capped at 300mg. This
allows bolus administration in anaesthetic room.
5. Frequency of administration: Antibiotic prophylaxis is generally indicated as a single do se
only. The exceptions to this recommendation would be instances of surgery involving
potentially high contamination such as large bowel intervention or alternatively the insertion
of prostheses. In these circumstances, 24 hour coverage would be warranted.
However, in all operations, if extensive blood loss occurs intraoperatively or the operation is
significantly prolonged, a second dose may be needed as follows:
a. More than 1.5 litre intra-operative blood loss:
Re-dose following fluid replacement giving same dose for all agents except
gentamicin (give half dose) and teicoplanin (do not redose).
b. Operation prolonged:
i. > 4 hours (re-dose flucloxacillin)
ii. >8 hours (re-dose flucloxacillin, co-amoxiclav, metronidazole and,
if eGFR>60ml/min, administer another full dose of gentamicin.
iii. Do not redose, teicoplanin or clarithromycin.
6. De-colonise MRSA positive patients prior to surgery unless risk of postponing the operation
is deemed too high; in such circumstances and in the case of complex individual prophylaxis
issues, discussed with infection control pre-operatively.

2
 Discuss with infection control (4528) if patient is MRSA positive or has a
history of MRSA infection / colonisation in the previous twelve months, or
has been in hospital for more than a week before operation
Antibiotic
Operation Standard prophylaxis Documented penicillin allergy
prophylaxis
Antibiotic choice & dose Additional Antibiotic choice & dose Additional
administer ≤30 min before post-op administer ≤30 min before post-op
operation doses operation doses

1 NEUROLOGICAL SURGERY Likely organisms: Staphylococci

1.1 Craniotomy Recommended

Cerebrospinal fluid (CSF) Flucloxacillin Clindamycin

1.2 Recommended none none
shunt 2g IV 600mg IV

1.3 Spinal surgery Recommended

2 OPHTHALMIC SURGERY

Highly Preoperative 5% povidone-iodine drops

2.1 Cataract surgery
recommended + intracameral cefuroxime (1mg in 0.1mL) immediately after operation

2.2 Glaucoma or corneal grafts Recommended

Ceftriaxone Levofloxacin
none none
2g IV 500mg IV
2.3 Lacrimal duct surgery Recommended

3 FACIAL SURGERY Likely organisms: Staphylococci and anaerobic mouth flora

Open reduction and internal fixation of Clindamycin

3.1 Recommended 600mg IV
compound mandibular fractures Amoxicillin-clavulanate
none none
1.2g IV
Gentamicin
3.2 Orthognathic surgery Recommended IV per dosing schedule

Clindamycin 6-hrly
600mg IV x 3 doses
Amoxicillin-clavulanate 8-hrly
3.3 Intraoral bone grafting procedures Recommended
1.2g IV x 2 doses
Gentamicin
IV per dosing schedule none

See notes for redosing if:

>1.5 litre intra-operative blood loss
or
operation prolonged > 4 hours
 Discuss with infection control (4528) if patient is MRSA positive or has a
history of MRSA infection / colonisation in the previous twelve months, or
has been in hospital for more than a week before operation
Antibiotic
Operation Standard prophylaxis Documented penicillin allergy
prophylaxis
Antibiotic choice & dose Additional Antibiotic choice & dose Additional
administer ≤30 min before post-op administer ≤30 min before post-op
operation doses operation doses
Likely organisms: Staphylococci; where relevant - oral anaerobic flora and
4 HEAD & NECK INCLUDING ENT SURGERY
Gram negative bacilli

4.1 Facial surgery (clean) Not recommended Not applicable

Flucloxacillin 8-hrly
Facial plastic surgery Should be 2g IV x 2 doses Teicoplanin
4.2 none
(with implant) considered Gentamicin 400mg IV
IV per dosing schedule none
Head and neck surgery
4.3 Not recommended Not applicable
(clean, benign)

Head and neck surgery Amoxicillin-clavulanate

4.4 Recommended none Clindamycin
(clean, maligant; neck dissection) 1.2g IV
600mg IV
none
Amoxicillin-clavulanate
Gentamicin
Head and neck surgery 1.2g IV
4.5 Recommended none IV per dosing schedule
(contaminated/clean-contaminated) Gentamicin
IV per dosing schedule

4.6 Complex septorhinoplasty (including grafts) Recommended Clindamycin

600mg IV
Amoxicillin-clavulanate
none none
1.2g IV
Gentamicin
4.7 Cleft lip and palate Recommended IV per dosing schedule

Ear surgery
4.8 Not recommended Not applicable
(clean/clean-contaminated)

Routine nose, sinus and endoscopic sinus

4.9 Not recommended Not applicable
surgery

4.10 Tonsillectomy Not recommended Not applicable

4.11 Adenoidectomy (by curettage) Not recommended Not applicable

Hydrocortisone acetate Hydrocortisone acetate

4.12 Grommet insertion Recommended + gentamicin sulphate none + gentamicin sulphate none
ear drops ear drops

See notes for redosing if:

>1.5 litre intra-operative blood loss
or
operation prolonged > 4 hours
 Discuss with infection control (4528) if patient is MRSA positive or has a
history of MRSA infection / colonisation in the previous twelve months, or
has been in hospital for more than a week before operation
Antibiotic
Operation Standard prophylaxis Documented penicillin allergy
prophylaxis
Antibiotic choice & dose Additional Antibiotic choice & dose Additional
administer ≤30 min before post-op administer ≤30 min before post-op
operation doses operation doses

5 CARDIAC AND THORACIC SURGERY Likely organisms: Staphylococci (including MRSA)

5.1 Breast cancer surgery Recommended

Breast surgery with implant (reconstructive

5.2 Recommended
or aesthetic) Flucloxacillin Clindamycin
none none
2g IV 600mg IV
5.3 Cardiac pacemaker insertion Recommended

Interventional cardiac catheter device Highly

5.4
placement recommended

5.5 Open heart surgery Recommended Flucloxacillin 6-hrly Teicoplanin

2g IV x 3 doses 400mg IV
none
Gentamicin Gentamicin
5.6 Pulmonary resection Recommended IV per dosing schedule none IV per dosing schedule

ABDOMINAL SURGERY
6 Likely organisms: Staphylococci; where applicable - coliforms
(NON-GASTROINTESTINAL)

Hernia repair
6.1 Not recommended Not applicable
(without mesh )
Hernia repair Consider in
6.2
(with mesh ) high risk
High risk: obesity, diabetes, immunosuppression or
co-existing infection at other sites Flucloxacillin Clindamycin
none none
Open/laparoscopic surgery with mesh (eg Consider in 2g IV 600mg IV
6.3
gastric band / rectoplexy) high risk
High risk: obesity, diabetes, immunosuppression or co-existing infection
at other sites

6.4 Diagnostic endoscopic procedures Not recommended Not applicable

6.5 Laparotomy Recommended Gentamicin Gentamicin

IV per dosing schedule IV per dosing schedule
Consider in none none
6.6 Splenectomy
high risk Metronidazole Metronidazole
High risk: immunosuppression 500mg IV 500mg IV

See notes for redosing if:

>1.5 litre intra-operative blood loss
or
operation prolonged > 4 hours
 Discuss with infection control (4528) if patient is MRSA positive or has a
history of MRSA infection / colonisation in the previous twelve months, or
has been in hospital for more than a week before operation
Antibiotic
Operation Standard prophylaxis Documented penicillin allergy
prophylaxis
Antibiotic choice & dose Additional Antibiotic choice & dose Additional
administer ≤30 min before post-op administer ≤30 min before post-op
operation doses operation doses
GASTROINTESTINAL & HEPATOBILIARY SURGERY Likely organisms: Staphylococci, coliforms; colonic surgery - anaerobes
7
If bowel perforation or rupture is diagnosed, manage as treatment not prophylaxis

7.1 Oesophageal surgery Recommended

7.2 Stomach and duodenal surgery Recommended

7.3 Gastric bypass surgery Recommended

Insertion of percutaneous endoscopic

7.4 Recommended
gastrostomy (PEG)

7.5 Small intestine surgery Recommended

7.6 Bile duct surgery Recommended

7.7 Pancreatic surgery Recommended

Gentamicin Gentamicin
7.8 Liver surgery Recommended IV per dosing schedule IV per dosing schedule
none none
7.9 Gall bladder surgery (open ) Recommended Metronidazole Metronidazole
500mg IV 500mg IV
Consider in
7.10 Gall bladder surgery (laparoscopic)
high risk

High risk: intraoperative cholanigiogram, bile spillage, conversion to

laparotomy, jaundice, pregnancy, immunosuppression, insertion of
prosthetic devices, acute cholecystitis/pancreatitis

Therapeutic endoscopic procedures -

endoscopic retrograde cholangio- Consider in
7.11
pancreatorgraphy (ERCP) and percutaneous high risk
endoscopic gastrostomy

High risk: immunosuppression, pancreatic pseudocyst, incomplete biliary

drainage (eg primary sclerosing cholangitis or cholangiocarcinoma)

Highly
7.12 Appendicectomy
recommended
Metronidazole 8-hrly Metronidazole 8-hrly
Highly 500mg IV x 2 doses 500mg IV x 2 doses
7.13 Colorectal surgery
recommended Gentamicin Gentamicin
IV per dosing schedule none IV per dosing schedule none

See notes for redosing if:

>1.5 litre intra-operative blood loss
or
operation prolonged > 4 hours
 Discuss with infection control (4528) if patient is MRSA positive or has a
history of MRSA infection / colonisation in the previous twelve months, or
has been in hospital for more than a week before operation
Antibiotic
Operation Standard prophylaxis Documented penicillin allergy
prophylaxis
Antibiotic choice & dose Additional Antibiotic choice & dose Additional
administer ≤30 min before post-op administer ≤30 min before post-op
operation doses operation doses

8 ORTHOPAEDIC SURGERY Likely organisms: Staphylococci; in open fractures - mixed flora;

Teicoplanin
Flucloxacillin 6-hrly
400mg IV
Arthroplasty 2g IV x 3 doses
Highly none
8.1 and any surgery involving Gentamicin
recommended Gentamicin
insertion of implant IV per dosing schedule none
IV per dosing schedule
Antibiotic-loaded cement (1 gram of tobramycin to 40 grams of powder) is
recommended as an adjunct to intravenous antibiotics
8.2 Surgery (without implant ) Not recommended
Not applicable
8.3 Arthroscopy Not recommended

Flucloxacillin Clindamycin
8.4 Soft tissue surgery of the hand Recommended none none
2g IV 600mg IV
Highly
8.5 Hip fracture repair
recommended Flucloxacillin 6-hrly Teicoplanin
Highly 2g IV x 3 doses 400mg IV
8.6 Hemiarthroplasty
recommended none
Open reduction with Highly Gentamicin Gentamicin
8.7
internal fixation recommended IV per dosing schedule none IV per dosing schedule

Highly
8.8 Open fracture
recommended Grade 3 fractures: treat for 72 hours or until soft tissue coverage of wound.

9 GYNAECOLOGICAL Likely organisms: Staphylococci and anaerobes; in obstetrics - Streptococci

9.1 Abdominal hysterectomy Recommended

Metronidazole Metronidazole
500mg IV 500mg IV
9.2 Vaginal hysterectomy Recommended none none
Gentamicin Gentamicin
IV per dosing schedule IV per dosing schedule
9.3 Pelvic floor repair Recommended

9.4 Assisted delivery Not recommended Not applicable

Highly
9.5 Caesarean section
recommended

Consider in
9.6 Perineal tear
high risk Amoxicillin-clavulanate Clindamycin
none none
1.2g IV 600mg IV
High risk: third/fourth degree perineal tears involving the anal
sphincter/rectal mucosa

9.7 Manual removal of the placenta Recommended

9.8 Evacuation of incomplete miscarriage Not recommended Not applicable

See notes for redosing if:

>1.5 litre intra-operative blood loss
or
operation prolonged > 4 hours
 Discuss with infection control (4528) if patient is MRSA positive or has a
history of MRSA infection / colonisation in the previous twelve months, or
has been in hospital for more than a week before operation
Antibiotic
Operation Standard prophylaxis Documented penicillin allergy
prophylaxis
Antibiotic choice & dose Additional Antibiotic choice & dose Additional
administer ≤30 min before post-op administer ≤30 min before post-op
operation doses operation doses

10 UROGENITAL Likely organisms: Staphylococci, coliforms; where relevant - anaerobes

Ciprofloxacin 750mg Ciprofloxacin 750mg

10.1 Transrectal prostate biopsy Recommended orally one hour before none orally one hour before none
operation operation

10.2 Cystoscopy Not recommended

10.3 Nephrectomy Not recommended Not applicable

Clean, open and laparoscopic urological

10.4 Not recommended
surgery
Clean-contaminated surgery Gentamicin Gentamicin
10.5 Recommended none none
(opening of urinary tract ) IV per dosing schedule IV per dosing schedule
Gentamicin Gentamicin
Clean-contaminated surgery
IV per dosing schedule IV per dosing schedule
10.6 (using bowel segments or manipulation of Recommended none none
Metronidazole Metronidazole
bowel )
500mg IV 500mg IV
Endoscopic ureteric stone
10.7 Recommended
fragmentation/removal
Extracorporeal shock wave lithotripsy
10.8 Recommended
(ESWL )

10.9 Pyeloplasty Recommended

Surgery for vesicoureteric reflux Gentamicin Gentamicin

10.10 Recommended none none
(endoscopic or open) IV per dosing schedule IV per dosing schedule

Transurethral resection of the prostate Highly

10.11
(TURP) recommended
Transurethral resection of bladder tumour Consider in
10.12
(TURB) high risk

High risk: large/necrotic tumours

Consider in
10.13 Percutaneous nephrolithotomy
high risk Ciprofloxacin 500mg 12-hrly
orally for one week preoperatively
High risk: patients with stone ≥ 20mm or with pelvicalyceal dilation

10.14 Radical cystectomy Recommended

Gentamicin Gentamicin
IV per dosing schedule IV per dosing schedule
10.15 Radical prostatectomy Recommended none none
Metronidazole Metronidazole
Urethroplasty 500mg IV 500mg IV
10.16 Recommended
(without free flap )

See notes for redosing if:

>1.5 litre intra-operative blood loss
or
operation prolonged > 4 hours
 Discuss with infection control (4528) if patient is MRSA positive or has a
history of MRSA infection / colonisation in the previous twelve months, or
has been in hospital for more than a week before operation
Antibiotic
Operation Standard prophylaxis Documented penicillin allergy
prophylaxis
Antibiotic choice & dose Additional Antibiotic choice & dose Additional
administer ≤30 min before post-op administer ≤30 min before post-op
operation doses operation doses
Ciprofloxacin 12-hrly
Amoxicillin-clavulanate 8-hrly 200mg IV x 5 doses
Free flap urethroplasty 1.2g IV x 8 doses Metronidazole 8-hrly
10.17 Recommended
(with buccal mucosal graft ) 500mg IV x 8 doses
Switch to oral as soon as patient condition permits
Gentamicin Gentamicin
IV per dosing schedule IV per dosing schedule
10.19 Scrotal procedures Recommended none none
Metronidazole Metronidazole
500mg IV 500mg IV
Circumcision
10.20 Not recommended
(routine elective)
Not applicable
10.21 Hydrocoele/hernia repair Not recommended

11 VASCULAR SURGERY Likely organisms: Staphylococci, anaerobes

Amoxicillin-clavulanate 8-hrly Teicoplanin none

1.2g IV x 2 doses 400mg IV
Abdominal and lower limb arterial
11.1 Recommended
reconstruction
Gentamicin Metronidazole 8-hrly
IV per dosing schedule none 500mg IV x 2 doses
Teicoplanin* none
Amoxicillin-clavulanate 8-hrly 400mg IV
1.2g IV x 2 doses Metronidazole 8-hrly
11.2 Lower limb amputation Recommended 500mg IV x 2 doses

*Use teicoplanin if: previous/ current MRSA carriage, antibiotic therapy in

previous 4 weeks, poorly controlled diabetes, tissue loss or recent foot sepsis.

12 OTHER SURGERY (where indicated)

Consider in
12.1 Cosmetic surgery
high risk
Flucloxacillin Clindamycin
none none
2g IV 600mg IV
High risk: procedures on the lower extremities or groin, for wedge
excisions of the lip and ear, skin flaps on the nose, skin grafts, extensive
inflammatory skin disease
Clindamycin
Clean-contaminated procedures Amoxicillin-clavulanate 600mg IV
12.1 Recommended none none
(where no specific evidence is available ) 1.2g IV Gentamicin
IV per dosing schedule
Flucloxacillin 8-hrly
Insertion of a prothetic device or implant 2g IV x 2 doses Teicoplanin
12.2 Recommended none
(where no specific evidence is available ) Gentamicin 400mg IV
IV per dosing schedule none

See notes for redosing if:

>1.5 litre intra-operative blood loss
or
operation prolonged > 4 hours
 Discuss with infection control (4528) if patient is MRSA positive or has a
history of MRSA infection / colonisation in the previous twelve months, or
has been in hospital for more than a week before operation
Antibiotic
Operation Standard prophylaxis Documented penicillin allergy
prophylaxis
Antibiotic choice & dose Additional Antibiotic choice & dose Additional
administer ≤30 min before post-op administer ≤30 min before post-op
operation doses operation doses

13 INTRAVASCULAR CATHETER INSERTION

• non-tunnelled central
13.1 Not recommended
venous catheter (CVC)
Not applicable
13.2 • tunnelled CVC Not recommended

14 PROPHYLAXIS OF INFECTIVE ENDOCARDITIS Likely organisms: Streptococci

Recommended for:
* Dental procedures involving manipulation of gingival tissue or the
periapical region or incision/perforation of oral mucosa
* Respiratory tract procedures involving incision or biopsy of the
respiratory tract mucosa e.g. tonsillectomy
in patients with:

Prosthetic cardiac valve or prosthetic material used for cardiac
Amoxicillin oral Clindamycin oral
valve repair
2 grams (adult); 600 mg (adult);

Previous IE
50 mg/kg (children) 20 mg/kg (children)

Congenital heart disease (CHD):
or none or none
– Unrepaired cyanotic CHD, including palliative shunts and Amoxicillin IV Clindamycin IV
conduits. 1 gram (adult); 600 mg (adult);
50 mg/kg (children) 20 mg/kg (children)
– Completely repaired congenital heart defect with prosthetic
material or device, during the first 6 months after the procedure.

– Repaired CHD with residual defects at the site or adjacent to

the site of a prosthetic patch or prosthetic device

Cardiac transplantation recipients who develop cardiac

valvulopathy

See notes for redosing if:

>1.5 litre intra-operative blood loss
or
operation prolonged > 4 hours
 SURGICAL PROPHYLAXIS RECOMMENDATIONS FOR THE 100 MOST COMMON OPERATIONS
PERFORMED AT MATER DEI HOSPITAL

Type Descriptive category ICD-9CM-PCS Prophylaxis requirement Reference

Laminectomy 03.09 Recommended 1.3

Neurological
Destruction of cranial and peripheral nerves 04.20 Not recommended
Forceps dental extraction 23.09 Not recommended
Facial
Surgical dental extraction 23.19 Not recommended
Excision of chalazion or other minor lesion of eyelid 08.21 Not recommended
Manipulation of lacrimal passage (LSWO) 09.49 Recommended 2.3
Phacomulsification and aspiration of cataract (PHACO) 13.41 Recommended 2.1
Ophthalmic Insertion of intraocular lens 13.71 Recommended 2.1
Repair of retinal tear by laser photocoagulation 14.34 Not recommended
Vitrectomy + pars plana approach 14.74 Recommended 2.1
Intravitreal Avastin injection 14.99 Recommended 2.1
Unilateral thyroid lobectomy 06.20 Not recommended
Excision or destruction of lesion in external ear 18.29 Not recommended
Myringotomy 20.09 Not recommended
Rhinoscopy (flexible nasal endoscopy) 21.21 Not recommended
Head and neck Submucous resection of nasal septum 21.50 Not recommended
Turbinectomy 21.61 Not recommended
Septoplasty 21.88 Not recommended
Tonsillectomy / adenoidectomy 28.20 Not recommended
Laryngoscopy and other tracheoscopy 31.42 Not recommended
Percutaneous Coronary Intervention (PCI) 36.05 Not recommended
Aortocoronary bypass 36.12 Recommended 5.6
Insertion of temporary transvenous pacemaker 37.78 Recommended 5.6
Initial insertion of single chamber device 37.82 Recommended 5.6
Initial insertion of dual chamber device 37.83 Recommended 5.6
Insertion Hickman, vascath, CVP 38.93 Not recommended
Cardiac &
Radical excision of axillary lymph nodes 40.51 May be considered 5.1
Thoracic
Local excision of lesion of breast 85.21 May be considered 5.1
Resection of quadrant of breast 85.22 Recommended 5.1
Incision with drainage of abscess or cyst 86.04 Treatment
Angiocardiography 88.53 Not recommended
Coronary arteriography 88.56 Not recommended
Bronchoscopy 33.23 Not recommended
Umbilical herniorraphy (includes Mayo's) 53.49 May be considered 6.2
Abdominal Laparatomy 54.11 Recommended 6.5
Laparascopy 54.21 Not recommended
Gastroscopy 44.13 Not recommended
Endoscopy of small intestine (OGD) 45.13 Not recommended
Colonoscopy 45.23 Not recommended
Flexible sigmoidoscopy 45.24 Not recommended
Appendectomy 47.09 Recommended 7.12
Rigid proctosigmoidoscopy (sigmoidoscopy) 48.23 Not recommended
Ligation of hemorrhoids 49.45 Not recommended
Gastrointestinal Excision of hemorrhoids 49.46 Not recommended
Endoscopic retrograde cholangiopancreatography (ERCP) 51.10 Recommended 7.11
Cholecystectomy 51.22 Recommended 7.6
Laparoscopic cholecystectomy 51.23 Recommended 7.6
Endoscopic sphincterotomy and papillotomy 51.85 Not recommended
Excision of pilonidal cyst or sinus 86.21 Not recommended
Digital examination of rectum 89.34 Not recommended
Dilation of anal sphincter 96.23 Not recommended
 Release of carpal tunnel 04.43 Not recommended
Removal of implanted devices from bone 78.67 Not recommended
Closed reduction of fracture without internal fixation 79.02 Not recommended
Open reduction of fracture with internal fixation 79.36 Recommended 8.7
Closed reduction of dislocation 79.71 Not recommended
Arthroscopy 80.26 Not recommended
Orthopaedic Excision of intervertebral disc (discectomy) 80.51 Recommended 1.3
Partial hip replacement (Hemiarthroplasty) 81.52 Recommended 8.1
Total knee replacement 81.54 Recommended 8.1
Injection of therapeutic substance into joint or ligament 81.92 Not recommended
Exploration of tendon sheath of hand 82.01 Not recommended
Other incision of soft tissue of hand 82.09 Not recommended
Application of cast 93.53 Not recommended
Insufflation of fallopian tube (TPT) 66.80 Not recommended
Cervical biopsy 67.12 Not recommended
Cautery cervix 67.32 Not recommended
Cervical polypectomy 67.39 Not recommended
Digital examination of uterus 68.11 Not recommended
Hysterescopy 68.12 Not recommended
Total abdominal hysterectomy 68.40 Recommended 9.1
Obs & Gynae
Vaginal hysterectomy 68.59 Recommended 9.2
Dilation and curettage (D&C) 69.09 Not recommended
Insertion of ICD 69.70 Not recommended
Vaginoscopy (colposcopy) 70.21 Not recommended
Repair of vagina (PFR) 70.79 Recommended 9.3
Biopsy of vulva 71.11 Not recommended
Low cervical caesarean section (LSCS) 74.10 Recommended 9.5
Transurethral removal of stone 56.00 Recommended 10.7
Ureteroscopy 56.31 Not recommended
Cystoscopy 57.32 Not recommended
Cystodiathermy 57.49 Not recommended
Insertion of indwelling catheter 57.94 Not recommended
Dilation of urethra 58.60 Not recommended
Ureteral catheterization 59.80 Not recommended
Urogenital
Needle biopsy of prostate 60.11 Recommended 10.1
Transurethral prostatectomy (TURP) 60.29 Recommended 10.11
Orchiopexy 62.50 Recommended 10.19
Excision of other lesion in spermatic cord and epididymis 63.10 Recommended 10.19
Circumcision 64.00 Not recommended
Retrograde pyelogram 87.74 Not recommended
Removal of ureterostomy tube and ureteral catheter 97.62 Not recommended
Ligation and stripping of varicose veins (lower limb veins) 38.59 Not recommended
Vascular
Amputation 84.10 Recommended 11.2
Incision of soft tissue 83.09 Not recommended
Excision and debridement of wound, infection or burn 86.22 Treatment
Local excision or destruction of skin lesion 86.30 Not recommended
Other surgery
Radial excision of skin lesion 86.40 Not recommended
Suturing LCW / soft tissue 86.59 Not recommended
Free skin graft 86.60 May be considered 12.1